ACO Proposed Rules Spotlight Physician-Hospital Alignment

Healthcare industry groups have offered guarded support for ACOs, but are still sifting through the details. America's Health Insurance Plans, for example, has raised concerns that hospitals and ACO collaborations could forge monopolies for their service areas and dictate higher prices.

Keckley says the proposed guidelines attempt to deal with the "unforeseen."

"I read carefully the discussion of antitrust safety zones, how primary service areas are defined, the 30% threshold," he says. "The language in the guidance suggests that they have been very thoughtful about waivers and antitrust. And, they have maybe been cautious thinking about what will happen if commercial health plans piggyback the ACOs and use them as their contracting organizations. Does that consolidate power? Does it create cartels? I was impressed by the granularity of the language in that section."

The American Hospital Association has raised concerns that the guidelines might not adequately address clinical barriers among caregivers. Keckley says that by identifying the 65 measures in five quality areas – including patient safety, patient experience, care coordination, preventive care, and at-risk populations – the feds "are going as about as far as they can."

"Clinical integration is really a loaded term because it means the doctors and hospitals have to work together and that is not easy," he says. "So, it's one thing to get the evidence and build the evidence-based guideline algorithms. It's another thing to get everybody in one room and say 'we all agree.' I don't think that is a shortcoming of the guidance as much as it is the history of our industry. It's tough for organizations to work together."

The American Medical Association raised concerns that the capital requirements for ACOs might be too highfor many physicians. "It's a fair concern anytime you inject a change into the system as to the cost of implementing something new and where is that cost borne," Keckley said. "I read explicitly that CMS is asking for guidance around several areas. This is one of four identified as an area looking for input."